LGBTQ+ Stigma and Health Effects: A Systematic Review of the Global Literature

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Introduction
This systematic review examines the global literature on stigma and health among LGBTQ+ community members.Each community has individual health concerns and situations unique to its identity.We define LGBTQ+ as, with particular attention to underserved communities, including men who have sex with men (MSM), lesbian women, transgender or gender nonconforming (TGNC), sexual minority men/women (SMM/SMW), and queer and intersex identities.Individuals who present themselves as gender non-conforming are more likely to be perceived as a sexual minority, resulting in greater vulnerability (Johnson & Ghavami, 2011;Rieger et al., 2010;Valentova et al., 2011).Stigma, prejudice, and discrimination create a hostile and stressful environment that causes mental health issues in minority communities (Meyer, 2003).Stigma, defined as a negative social attitude or devaluation attached to a characteristic of an individual and is considered mentally, physically, or socially inferior (Scott, 2022), can be exerted in multiple ways: verbal attacks, violence, heterosexism, or inattentive care (Gyamerah et al., 2020;Chan, 2022;Paine, 2021).Interacting with these behaviors negatively affects the health of LGBTQ+ individuals (Balsam et al., 2013;Douglass & Conlin, 2020;Hatzenbuehler, 2009;Meyer, 2003).In addition, stigma is more closely related to an individual's level of gender nonconformity in a specific cultural context rather than their sexuality (Rieger & Savin Williams, 2012).These findings point to the need for a worldwide view of LGBTQ+ health and stigma, especially in vulnerable subpopulations.
Multiple forms of stigma impact LGBTQ+ health concerns, with the most well-known example being the HIV epidemic that disproportionately affects MSM.HIV/AIDS appeared in the 1980s, affecting healthy young men in the United States; the CDC was not able to identify how this infection was transmitted, which caused the public to assume that HIV only affected gay men.Those diagnosed with HIV were then stigmatized, affecting how HIV was treated in healthcare spaces (CHLP, 2015).Today, these misconceptions still impact gay men, evinced by gay, bisexual, queer, and other MSM (GBQMSM) being more vulnerable to HIV (CDC, 2018).Therefore, more research on the intersection between stigma and health among disadvantaged communities has become essential.Further, this present-day threat of extensive stigma even translates into LGBTQ+ individuals being unable to get tested for HIV.
In addition, due to the stigma that surrounds HIV, the testing and disclosure of HIV status is still a struggle in LGBTQ+ communities.Sexual health is another aspect in which LGBTQ+ members are disparaged, as there are higher rates of HIV and other STIs (Logie, Navia, & Loutfy, 2015;Puckett et al., 2017;Hafeez et al., 2017).A recent survey revealed that 21% of their GBQMSM participants believed most people discriminated against people living with HIV (PLWH) (Beltran et al., 2020).Corroborating this sentiment, 17.5% of US adults feared physical contact with PLWH, while 12.5% expressed some moral judgment (Pitasi et al., 2018).Those trying to acquire HIV testing suffered from stigma for both their sexual behavior and their sexual orientation (Hutchinson et al., 2004), which in turn prevented these individuals from seeking HIV and other STI testing.Consequently, LGBTQ+ populations remain vulnerable to HIV/STIs, and LGBTQ+ HIV patients are at a greater risk of death (Leserman, 2008).
A few previous literature reviews examined specific health issues among LGBTQ+ communities.Aleshire's (2019) literature review showed that primary care providers (PCP) mainly had favorable opinions of LGBTQ+ individuals and suggested addressing disparities in healthcare on an individual case basis.Saraff's (2022) review on the stigma and Indian LGBTQ+ health demonstrated that social rejection negatively impacted Indian LGBTQ+ both psychologically and sexually.Finally, Correro (2020) reviewed the minority stress and cognitive decline of older LGBTQ+ individuals, exposing that long-term stress hormones accelerated brain aging, and suggested action toward the effort of preventing cognitive health risks.To extend these previous reviews, we intend to synthesize existing findings from numerous global studies on LGBTQ+ communities, capturing mental, sexual, and physical health.The current review intends to reveal the effects of stigma on LGBTQ+ health from a more comprehensive perspective.Broadening the scope of the reviewed research worldwide, spanning from high-and low-income countries, will allow us to grasp an extensive picture of the current situations on a global scale.

Inclusion Criteria
We identified studies that are: (1) peer-reviewed and published in English-language journals before January 17, 2023; (2) empirical studies using either qualitative or quantitative methodology; (3) studies that focused on LGBTQ+ (lesbian, gay, bisexual, transgender, queer) as the primarily targeted study population; (4) engaged in assessing the association between stigma and health issues (e.g., inequalities, discrimination, effects, etc.) among LGBTQ+ populations.

Data Sources
The literature search was conducted in January 2023 using four electronic bibliographic databases: CINAHL, PsycINFO, PubMed, and Web of Science.We generated a master list of search terms and tailored search queries to each electronic database.The search terms included "LGBTQ," "stigma," and "health."All citations were imported into EndNote Online for data management.The search of these four databases resulted in 714 total citations.After deleting duplications, 596 citations remained in the EndNote data set for further screening.

Screening
Citations were screened using a three-step process, including a title (and keyword) review, an abstract review, and an article review.All unduplicated records [n=596] were initially screened at the title review stage to exclude citations that did not provide empirical data for LGBTQ+ stigma and health effects.As a result, we excluded 373 articles: 18 irrelevant citations, 20 non-empirical studies, and 335 articles that focused on only one or two of our three primary topics of interest (i.e., LGBTQ, health, or stigma).At the abstract review stage, we excluded 142 of the remaining 223 articles either because they did not examine the relationships between stigma and health in LGBTQ+ populations or focused on only one of our three primary topics.At the article review stage, we excluded 32 of the remaining 81 articles because 25 did not provide data about the relationship between health and stigma of LGBTQ+ communities, and the remaining six focused on only one or two of our three primary topics.The three-step screening process left 49 peer-reviewed articles.The references of these 49 eligible articles were then hand-searched; at this stage, one additional article was identified.The search yielded 49 eligible articles reporting data from 46 studies for further analysis.Figure 1 illustrates the screening process for each step and presents the reasons for exclusion.
Figure 1.The screening process for each step and presents the reasons for exclusion

Data Abstraction
We developed structural data abstraction forms to retrieve study characteristics and significant findings from each of the 44 reviewed articles.We then created a table to display and categorize the study characteristics (e.g., study location, study sample and size, year of data collection, age of study sample, and study design) for each reviewed article.We also created a table (Appendix Table 1) that displays the discrimination faced by LGBTQ+ and the resulting impacts on health (mental/physical health, suicide ideality, alcohol/drug use, healthcare experiences, and HIV/AIDS/other diseases, PrEP) for the data we extracted.

Study Sites and Publication Period
The key characteristics of the reviewed studies were summarized by authors, publication year, study site, year of data collection, study sample, sample size, sample's mean age, and the chosen study design.Participants in the selected studies were recruited from 15 different countries.54% of the studies were based in the United States, in addition to 1 being based in Mexico, 1 in Brazil, 1 in Australia, 6 in Europe, 2 in Asia, and 2 in Africa.Nine studies were published before 2020, and the rest were published after 2020.

Study Design and Sampling
Half of the studies were conducted using a quantitative method (23/46), 20 were qualitative studies, 1 study used mixed methods, 22 of the quantitative studies were conducted cross-sectionally, and only one was done longitudinally.Sample sizes ranged from 6 to 3,549 participants.Twelve articles had 100 or fewer participants, 11 studies had 100-500 participants, seven studies had 500-1,000 participants, and six studies had 1,000 or more participants.

Target Population
Illustrated in Table 1, 15 studies focused on LGBTQ+ populations without the specifics of race, gender, or ethnicity.Six studies covered just transgender adults.Seven studies covered only gay men.Four studies covered only lesbian or sexual minority women.Two articles covered black sexual minority males (one in youth).Two articles covered male Latino sexual minorities.Two articles covered healthcare professionals.One article covered Latino LGBTQ+ members.Two articles covered young sexual minorities.One article covered PLHIV.One article covered black LGBTQ+ members.One article covered sexual and gender minorities of color.Finally, 1 article covered ethnically diverse sexual minorities.Seven studies did not provide a mean age of their study sample.The average age of the studies that provided this number ranged from 18.8 to 55.2 years old.One study had average participants in their late teens, 15 studies had average participants in their 20s, 10 studies in their 30s, 3 studies in their 40s, and 1 article averaged in their 50s.Iott et al., 2022;Ghabrial, 2017;Wang et al., 2022).Their data were primarily quantitative, except for one qualitative study (Scandurra et al., 2020;Ronzón-Tirado et al., 2022).Studies also conducted mediation analyses and identified factors that helped mediate or reduce the impact of stigma on depression or depressive symptoms: connectedness or social support (Drabble et al., 2022), expressive writing (Pachankis et al., 2020), mentalization (Scandurra,2020), and resilience (Wang et al., 2022;Koziara et al., 2022).In contrast, others found that openness did not have a net benefit for LGBTQ+ mental health, possibly because LGBTQ+ individuals would increase their perception of discrimination as a result (Suppes, van der Toorn, & Begeny, 2021).Another study found that LGBTQ+ individuals received more significant stigma for having mental illness over simply being part of the LGBTQ+ community (O'Connor, Pleskach, & Yanos, 2018).Stress was another common theme in the mental health concerns of LGBTQ+ individuals, as they were found to have additional sources of stress such as HIV testing, rejection, LGBTQ+ community standards, homonegativity/heterosexism, and limited resources due to their LGBTQ+ identity (Iott et al., 2022;Ghabrial, 2017).

Physical Health
Selected studies concluded a similar outcome regarding the physical health consequences of stigma.The themes included general physical health, self-harm, digestion, physical and sexual violence, and fear during physical health exams (pap smears, breast exams, misdiagnoses, etc.).Studies frequently found harmful effects on health caused by stigma either through qualitative calculations or qualitative collections on the state of participants' physical health or experiences with healthcare appointments (Chan, 2022;English et al., 2022;Ghabrial, 2017;Gyamerah et al., 2020;Dsouza et al., 2023;Logie et al., 2019;Milner & McNally, 2020;Paine, 2021;Wolfe et al., 2022).The most common theme was stigma causing anxiety among LGBTQ+ individuals, which led them to avoid healthcare and tend to their health concerns (this theme will be mirrored in the healthcare services findings as well, proving to be significant with regards to LGBTQ+ health conditions).

Eating Disorders
One article examined eating disorders in LGBTQ+ communities (Bell, Rieger, & Hirsch, 2019); 47.6% of gay men were eating disorder prone, 66.7% of lesbians were eating disorder prone, and 62.6% of TGNC were eating disorder prone; depression symptoms significantly correlated with eating disorder proneness in gay, lesbian, and TGNC participants.Additionally, perceived stigma was also a driving factor that increased the likelihood of an eating disorder in someone who is part of the LGBTQ+ community; this is due to stigma in the community itself holding rigid beauty standards among individuals through ostracizing overweight individuals.
LGBTQ+ individuals of color received stigma in both LGBTQ+ and ethnic minority spaces (Ghabrial, 2017;MacCarthy et al., 2021;Quinn et al., 2022).Ranjit et al. (2021) found HIV stigma in the context of Spanish-speaking communities to match that of English-speaking communities.

HIV Discrimination
Four articles included HIV discrimination (Bogart et al., 2020;Iott et al., 2022;Quinn, 2022).Common themes were HIV being labeled as "dirty" and "slutty" in the LGBTQ+ community dating scenes (Iott et al., 2022) and how these attitudes prevented LGBTQ+ individuals from getting tested for HIV or avoiding PrEP use (Quinn et al., 2022).This form of discrimination had primarily adverse effects on reproductive health and relationships with other LGBTQ+ community members.

Drug or Alcohol Abuse
Abuse of drugs and alcohol was relevant in 8 articles in the final selection (DiGuiseppi, 2022;Drabble et al., 2022;English et al., 2022;Logie et al., 2020;Lozano-Verduzco, Castillo, & Padilla-Gámez, 2019;Pachankis et al., 2020;Powers et al., 2021;Wolfe, 2021Wolfe, , 2022)).Patterns related to discrimination or stigma through social interactions or law increased LGBTQ+ participants' alcohol and drug use (DiGuiseppi, 2022;English et al., 2022;Logie et al., 2020;Powers et al., 2021;Wolfe,2021).These studies also found positive correlations between stigma and drug use.In this sense, drug use was a form of self-care where drugs and alcohol acted as coping mechanisms aimed at dealing with the emotional consequences of stigma.Additionally, family support and depression predicted higher rates of alcohol use disorder (AUD) (Drabble et al., 2022;Lozano-Verduzco, Castillo, & Padilla-Gámez, 2019).Substances were also used to mediate the relationship between transgender and gender diverse (TGD) stigma and HIV prevention clinic use (Wolfe, 2021(Wolfe, , 2022)).Finally, the high rate of alcohol use in LGBTQ+-connected spaces was found to be a common way for community members to bond (Logie et al., 2020).

Healthcare Services
Healthcare services were relevant to 12 articles and were primarily related to general primary care providers (PCP), quick clinics, and STI clinics.Themes of discrimination were prevalent in all of the selected studies.The historical context of how HIV/AIDS had impacted LGBTQ+ individuals was reflected in Twitter-based reactions to public health measures towards Mpox, which prioritized avoidant behavior (Dsouza et al., 2023).Other studies detailed that LGBTQ+ individuals experienced stigma or discrimination from healthcare providers (Henriquez & Ahmad, 2021;MacCarthy et al., 2021;Sileo et al., 2022;Stojanovski et al., 2022).Such stigma was manifested through judgment (Henriquez & Ahmad, 2021;MacCarthy et al., 2021) assumption of sexuality through HIV diagnosis (Henriquez & Ahmad, 2021;Iott et al., 2022), heteronormativity, cisnormativity, and lack of confidentiality (Iott et al., 2022;Logie, 2019;Schwab et al., 2024;Sileo et al., 2022;Stojanovski et al., 2022).In most cases, this discrimination caused LGBTQ+ individuals to avoid receiving healthcare at all (Logie et al., 2020;Smith, 2020;Stojanovski et al., 2022;Wolfe, 2022).Still, other studies reported that LGBTQ+ individuals also decided to avoid disclosing their sexual identity (Henriquez & Ahmad, 2021).These selected studies suggested that this phenomenon occurred because of the lack of LGBTQ+-focused education and suggested that medical providers receive more education on how to care for LGBTQ+ individuals.

HIV/AIDS
HIV and AIDS were brought up in 10 of the selected studies.Two articles (Gyamerah et al., 2020;Iott et al., 2022) covered LGBTQ+ HIV-testing patterns, four studies covered LGBTQ+ discrimination caused by their HIV status (Bogart et al., 2020;Logie et al., 2020;Moallef et al., 2022;Sileo et al., 2022), and two articles (Logie et al., 2020;Wolfe, 2022) described risk behaviors (substance use, condom use, "sexual risk") that caused LGBTQ+ communities to be more vulnerable to HIV.Additional details included sexual assault increasing HIV risk (Gyamerah, 2020;Logie et al., 2020) and HCP's assumptions of HIV-positive patients being homosexual (Sileo et al., 2022).A lack of education or training in patient providers explained healthcare-related findings.Sexual risk behaviors or promiscuity received an additional stigma from both healthcare and social circles (Iott et al., 2022).

PrEP
Two articles discussed PrEP use.PrEP use softened the HIV division on GBQMSM as PrEP reduces HIV risks (Iott et al., 2022).Daily discrimination was associated with the likelihood of using PrEP, as study participants with more significant concerns about PrEP use reported a lower connection to the Black LGBTQ+ community and were less likely to use PrEP in the future.Black LGBTQ+ members were subjected to HIV stigma in both black and LGBTQ+ communities; participants separated from fellow black LGBTQ+ communities were less likely to use PrEP, suggesting the critical role the community plays in maintaining good health (Quinn et al., 2022).

Miscellaneous Illnesses
Miscellaneous illnesses include Mpox and COVID-19 in an LGBTQ+ context.Two studies were included on this topic (Dsouza et al., 2023;Solomon et al., 2021).One study encompassed the positive and negative opinions of LGBTQ+ individuals concerning Mpox (Dsouza et al., 2023).
LGBTQ+ individuals felt uneasy about public health covering Mpox and felt that stigma against Mpox would prevent research on transmission and vaccinations for the illness.These concerns stem from the HIV epidemic due to the significant problem of Mpox being labeled as a 'gay disease.'Another study covered COVID-19 prevention behaviors among LGBTQ+ individuals and the role stigma played.Self-stigma (sexuality dissatisfaction) was used to predict people leaving home for nonessential reasons.Additionally, belief in negative stereotypes predicted less consistent handwashing and lower frequencies of both face mask use and social distancing in public places (Solomon et al., 2021).Finally, Sexual minorities had significantly more fear of COVID-19 and anxiety about potentially spreading COVID-19 to others when compared to heterosexual participants (Solomon et al., 2021).

Discussion
The current review synthesized the existing literature on social stigma and health conditions among LGBTQ+ individuals.Our review found a clear pattern that stigma has negatively impacted both LGBTQ+ physical and mental health.For example, HIV stigma is still prevalent among LGBTQ+ patients, particularly MSM, TGW, and male non-conforming individuals.Moreover, selected studies showed that extensive stigma in healthcare caused LGBTQ+ patients to avoid healthcare appointments, which further exacerbated their health conditions.At the same time, LGBTQ+ individuals in rural settings were limited to heteronormative or cisnormativity-centric healthcare.
While alcohol and drug use were exacerbated by stigma, these coping strategies were a method through which LGBTQ+ individuals built connectedness; the coping mechanisms should be further studied.Additional opportunities for connectedness and group therapy for LGBTQ+ individuals should be considered in hopes of mediating stigma and resulting adverse health effects.For example, programs that aim to strengthen the coping skills of Latino sexual minority men (LSMM) as potential levers may prove effective in addressing health disparities (MacCarthy et al., 2021).These programs can also center around promoting social connectedness, which supports the community's needs to lessen the impact of stigma.
Moreover, further research should be conducted on the social networks of LGBTQ+ individuals and communities.Some of the previous studies of LGBTQ+ networks explored discrimination and social support.The examined topics included schools, parental or family support, heterosexual versus homosexual social spaces, ethnic versus LGBTQ+ identities, and LGBTQ+ pride events.Studies of LGBTQ+ school networks showed that nursing coursework aimed at reducing HIV stigma promoted the presence of community leaders in healthcare (Bernstein et al., 2024), and peer victimization was associated with suicidality and negative social interactions (Hatchel, Merrin, & Espelage, 2019).Gay-straight alliance groups offered leadership opportunities, community opportunities, and safe spaces in schools (Porta et al., 2017).In addition, higher LGBTQ+ support predicted less suicidal behavior and ideation in LGBTQ+ Canadian students (Saewyc et al., 2020), and students who were in more supportive LGBTQ+ environments had lower rates of lifetime illegal drug use, marijuana use, and smoking.A higher number of LGBTQ+ pride events led to lower odds of substance use when compared to places with no LGBTQ+ events (Watson et al., 2020).Social support also remained a protective factor for aging LGBTQ+ adults utilizing healthcare (Loeb, Wardell, & Johnson, 2021).
Family support has been a significant topic in LGBTQ+ networks.For example, families were described as needing education to alleviate their shame towards LGBTQ+ family members in Brazil (Nakhid et al., 2022).In other contexts, however, parental support was seen to buffer the stress of disclosure and depression (Pollitt et al., 2017), even though the period of disclosure to the family was associated with anxiety or depression for fear of rejection (Sammut, 2021).Such findings coincided with a qualitative study showing that gay and lesbian participants with mental illness believed the benefits of disclosure were acceptance and comfort, yet was contrasted with shame, conformity, harm, and discrimination for holding dual disenfranchised identities (Corrigan et al., 2009).These findings indicate that the act of disclosure of sexuality is not easy and that openness and acceptance towards disclosure play an essential role in decreasing the anxiety of LGBTQ+ experiencing social stigma.
Social networks between LGBTQ+ individuals and heterosexuals have also been underscored in the existing literature.For instance, lesbian and gay people who felt that their LGBTQ+ ingroup was legitimate, porous, and stable compared to heterosexual outgroups engaged in individual strategies.On the other hand, interdependent groups were more likely to engage in a collective strategy (Aybar Camposano, Rodrigues, & Moleiro, 2022), while gay men were more likely to dissociate from LGBTQ+ ingroups.Stigma and respectability also caused gender silencing, exclusion, and rejection (Nakhid et al., 2022).Discrimination prevented LGBTQ+ individuals from seeking feelings of acceptance (Wilson & Liss, 2022).A few studies covered dialogues on substance use, queer health, and social responsibility in LGBTQ+ networks, acknowledging privilege, breaking stereotypes, and coalescent learning (Brondani et al., 2020).Primary concerns for transgender individuals were that of coming out, reciprocal support from relationships, social transitions, gender identity affirmations, and experiences in the LGBTQ+ community; the most essential aspect for transgender individuals was support from relational partners (Lewis, Barreto, & Doyle, 2023).In India, introducing a community-based theater increased acceptance of prosocial behaviors toward the LGBTQ+ community and led to a greater understanding of the importance of supporting LGBTQ+ individuals (Pufahl et al., 2021).The identified knowledge about social networks among LGBTQ+ individuals could be utilized for stigma reduction programs.
Furthermore, future studies should work to promote ways to educate and work with more LGBTQ+ healthcare providers (HCPs).
LGBTQ+ individuals largely believed their HCPs might hold biases and lack education on their needs (Coker et al., 2010;Sevelius et al., 2014), which prevented them from receiving healthcare, especially for HIV/STI testing (Kaufman, Avgar, & Mirsky, 2007;Whitehead, Shaver, & Stephenson, 2016).These barriers did impact the healthcare of LGBTQ+ communities, as evidenced by the higher prevalence of chronic conditions and STIs in LGBTQ+ patients compared to their heterosexual and cisgender counterparts (Centers for Disease Control and Prevention, 2018;Elliott et al., 2015;Simoni et al., 2017;Wanta et al., 2019).The effect of comradery cannot be understated; seeing other LGBTQ+ members existing in public spaces has positively affected a population's health, as demonstrated by findings among black LGBTQ+ individuals (Quinn et al., 2022).Having insider HCPs could aid in understanding the specific needs of LGBTQ+ communities; this could be another tool for addressing health disparities.Thus, various ways the LGBTQ+ community educates HCPs should be further examined.
Furthermore, future research should examine intersectional stigma among LGBTQ+ communities, as individuals may experience stigma for their sexuality, race, mental illness, HIV status, and other factors based on their identity (Chan, 2022;Bogart et al., 2020).For example, sexual minorities of color are at greater risk for poor mental and physical health because they experience racial discrimination in addition to sexual minority stressors (Balsam, Molina, Beadnell, et al. 2011;McConnell et al., 2018;Diaz et al., 2001).In the Arctic region of Canada, the colonization of indigenous people, insufficient healthcare resources, and limited transportation were a significant reason for avoiding healthcare (Allen, Levintova, & Mohatt, 2011;Law et al., 2008).Involvement in sex work was also associated with higher levels of stigma, discrimination, sexual abuse, torture, and attempted murder.For example, Dominican TGW who engaged in sex work received less social support than non-sex work peers (Milner et al., 2019); TGW involved in sex work were associated with a higher level of stigma, and those who experienced violence were at higher HIV risks (Budhwani et al., 2021).In addition, we should also consider the concerns of LGBTQ+ individuals from a culturally less accepting of sexual minorities (Ghabrial, 2017), which highlights the importance of local settings for inclusive care.
Moreover, future intervention programs targeting LGBTQ+ populations should spread to more remote, rural locations to mediate the mental, physical, and unfavorable healthcare experiences among rural LGBTQ+ individuals.There is an urgent need for more empirical studies on intersectional stigma -particularly those targeting the most vulnerable subpopulations among sexual minorities.Transgender people of color, for example, are relatively invisible in research and neglected in healthcare policy (Baur, Bruchez, & Schlaffer, 2013).Paying more attention to intersectional stigma will provide a more comprehensive and nuanced understanding of the intersections between stigma and various facets of identities.

Funding
The Western Washington University (WWU) supported supported the study.The content is the sole responsibility of the authors and does not necessarily represent the official views of WWU.

Informed Consent
Obtained.